PACCC Board of Directors & Committee Application
This form was designed so our Board can get to know you. Please share whatever information you think would help them do so and a PACCC representative will contact you to follow-up on your interest.

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What are you applying for?
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PACCC Enrollment Status
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First & Last Name *
Employer *
Job Title *
This will appear under your name on the  PACCC website. To see how PACCC board members are listed, visit http://paccc.org/about/board_of_directors.
Address *
Only shared internally and with the State licensing agency.
Phone *
Please include one or all of the following: home, work, mobile. Only shared internally and with the State licensing agency.
Preferred Email *
Only shared internally and with the State licensing agency.
Other Memberships in the Community *
Ex: PTA, Kiwanis, Library Foundation
I am applying because: *
LinkedIn Profile or Bio *
Leadership Experience
 *
Required
Functional Expertise
 *
Required
Background Check
Due to the nature of PACCC's operation, background checks will be conducted on applicants who are over 18 years of age. Please provide information below. Your information will be kept completely confidential.

CDSS Information on Background Checks: https://ccld.childcarevideos.org/child-care-center-operators/background-check-requirements-for-caregivers/
References *
Please include one personal and one professional reference (name, phone and email).
Will you be able to provide proof of a TB Test?
 *
Will you be able to provide immunization records for influenza (flu), pertussis (whooping cough) and measles?
 *
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